Even Folks in Our Field Get the Blues: When Implementation of Best Practices Goes Wrong, Part 1

By David S. Prescott, LICSW

A participant in a training recently described frustration in adopting Motivational Interviewing in their practice.  This confirmed a concern I’d seen expressed in social media. As the discussion progressed, another participant expressed similar experiences. Although small in number, their concerns were important: There can be side effects when adjusting to the use of positive, collaborative, strengths-based approaches such as Motivational Interviewing (MI) and the Good Lives Model (GLM). How can this be? What can we do?

First, it’s important to examine the context. In many instances, the complaint centres on probation officers and other supervising agents who come away from trainings believing that they now need to behave like therapists. Others have complained that they have to pay attention to how they respond and use reflective listening rather than focus on efforts at rehabilitation. Still, others feel cornered into working in a fashion that is at odds with their personal style. One person lamented that clients are challenging their treatment before they even get started. The result, in the estimation of these professionals, is that clients can appear more hostile, often with a sense of entitlement. Where public safety and client care are on the line, these are important concerns.

What do we know? First, the jury has returned on many of the characteristics of effective treatment for people who have abused. Marshall (2005) summarized findings showing that the most effective therapists are those who are warm, empathic, rewarding, and directive. In practice, any one or two of those qualities can be easy, but balancing all four can be a challenge. Three years later, Parhar and her colleagues demonstrated in a meta-analysis that the more coercive the treatment experience for mandated clients, the less effective they are. There’s really no question that the often harsh and confrontational practices of yesteryear don’t work and can make matters worse. It is no wonder that Moyers and Miller (2013) argued that low levels of demonstrated empathy are toxic. Since that time, the use of MI (and its derivatives) with criminal justice populations has only become more widespread. Earlier this year, Blasko and Taxman (2018) found that clients who perceived their probation officer as fair and respectful had lower rates of violating their conditions and returned to prison less frequently.

Does that really mean that effective practices create more problematic clients? I don’t believe so, although it’s an important question. Here’s what I mean:

First, clients feeling free to challenge their treatment and treatment providers at the outset may actually be preferable in the long run to clients who give the surface impression that they are actively engaged but in fact participating minimally. As the old adage goes, “A man convinced against his will is of the same opinion still.” Although every case is different, there may even be real merit in challenging one’s circumstances prior to making peace with them and getting involved in meaningful change processes. This idea is central to self-determination theory, which holds that extrinsic motivation often precedes intrinsic motivation. In the long run, pushing back against extrinsic motivators as a pathway to awakening internal motivation can have real value in treatment.

Further, there are contextual challenges with our training approaches. All too often, trainees are “voluntold” to attend trainings and adopt the new practices (that strange experience of being volunteered by a supervisor to participate against one’s will). Not surprisingly, there is a strong parallel process between the practitioner who is ambivalent about adopting new treatment methods and the client who is ambivalent about change. As much as agencies focus on what they believe are best practices, it is easy to forget the importance of the change process for the professional. Further, the fact that some agencies prefer some evidence-based approaches over others speaks to the fact that we are often not as evidence-informed as we would like to think.

Then, there are other problems with implementing new approaches. Often overlooked, an entire body of research has examined how treatment implementation efforts succeed and fail. Bringing in the expert from out of the area to do training is easy; implementing with fidelity and minimal attrition and client drop-out is another matter entirely. Often, this can occur when professionals only learn the basics and are expected to jump into practice. For example, many MI trainees wonder how they will carry out parts of their job (sometimes known as “telling the hard truth”) without having learned the explicit methods for doing so (for example, the elicit-provide-elicit method of providing information and feedback).

Finally, all of these efforts rest on the foundation of a strong working alliance. The alliance is often mistaken for having a good relationship with a client, but in fact has been defined for decades as having an agreement on the goals and tasks of treatment, as well as agreement on the nature of the working relationship. More recent conceptualizations consider the strong personal values and beliefs of the client. In my experience, many programs who seek enthusiastically to develop expertise in a specific model or set of techniques can also be those that rate themselves as doing well enough with their alliances that this needn’t be an ongoing area of focus for them. This is despite the fact that simply ensuring a solid alliance is itself a highly evidence-informed practice.  

In the end, when clients become challenging despite the available collaborative approaches, it may be as simple as returning to basic discussions about what the client wants out of the experience in order to establish goals. After that, the practitioner can work on gaining clarity on the exact nature of who the practitioner and client are so that they can agree on the nature of the relationship. Next, the practitioner may want to ensure that his or her approach is a good fit for the client, and consider a person’s unique characteristics, culture, values, and beliefs.

All too often, the problems lie not in the methods or models, but in the ways, we attempt to implement them. This can be especially problematic when we attempt to use newer methods without first ensuring a solid working alliance.